经皮主动脉瓣植入最全课件.ppt

1、经皮主动脉瓣植入QUIZ Street AvenueStreetAvenueHospital of UAHospital of UAHospital of UAHospital of UASummarize of TAVI Transcatheter aortic valve implantation(TAVI)It was introduced as an alternative treatment in patients with severe aortic valve stenosis(AS)Cribier A,Eltchaninoff H,Bash A,Circulation 2002

2、;106:30063008.First Case of TAVI In 2002,Cribier et al demonstrated for the first time the feasibility of a percutaneous valve implantation in a patient with AS Providing a promising less invasive alternative treatment for valvular heart diseaseCribier A,Eltchaninoff H,Bash A,Circulation 2002;106:30

3、063008.two different TAVI devices are widely used the balloon-expandable Edwards SAPIEN Transcatheter Heart Valve the self-expanding Medtronic CoreValve Both received CE Mark approval for European commercial sale in 2007 Edwards SAPIEN valve received FDA pre-market approval in the USA in November 20

4、11Two different TAVI devicesEdwards balloonexpandable delivery systemsCoreValve ReValving System(a)schemata and(b)following deployment with aortographyValve Malposition and EmbolizationAssessmentsAssessment of arterial accesscalcified pericardiumPatients SelectionIn particular,a transverse or extrem

5、ely unfolded ascending aorta may increase the diffi culty of delivery and positioning of the balloon-expandable devicesAssessment of aortic rootTwo different TAVI devicesHospital of UARequirements of TAVIComplications of TAVIRequirements of TAVIThis approach may be considered if the iliofemoral arte

6、rial system is of sufficiently small diameter,calcified,or tortuous and not technically suitable for delivery of the deviceprevious left ventricular surgery using a patchBoth received CE Mark approval for European commercial sale in 2007Both received CE Mark approval for European commercial sale in

7、2007the self-expanding Medtronic CoreValveCoreValve ReValving System(a)schemata and(b)following deployment with aortographyPatients Selection Feasible in most patients with severe aortic stenosis Generally utilized in patients not suitable for surgical AVR,who are likely to derive functional and sur

8、vival benefit Two risk scores are used to calculate the risk of cardiac surgery“High-risk”surgical patients Having a Society of Thoracic Surgeons Predicted Risk of Mortality(STS-PROM)at 30 days of greater than 10%Logistic EuroSCORE of greater than 20%Limited Do not account for several pertinent clin

9、ical risk factors,such as previous CABG,porcelain aorta,previous chest radiotherapy,severe lung disease,and liver cirrhosisTwo risk scoresTwo risk scoresAssessments of TAVI To assess the aortic annulus dimensions and geometry,access site,and approach Transthoracic echocardiography Coronary angiograp

10、hy Aortic angiography MDCTAssessment of arterial access The evaluation is fundamental in the assessment of the TAVI patient in minimizing potential major vascular complications Arterial dimensions The presence or absence of atheroma,Calcification TortuosityAssessment of arterial access Arterial acce

11、ss is assessed with the combination of invasive angiography and contrast-enhanced CT Iliofemoral assessment with(a)angiography and(b)MDCTAssessment of aortic root Using invasive angiography and contrast MDCT evaluate root and valvular calcification left main height from the left coronary cusp insert

12、ion(due to risk of coronary obstruction)technical issues related to each valve type and delivery systemEuropean Heart Journal(2014)35,26272638Assessment of aortic root(1)aortic annulus diameter,(2)sinus of Valsalva width(3)ascending aorta width,(4)sinus of Valsalva heightAssessment of aortic rootAss

13、essments Left and right heart catheterizations are also performed assess the presence of pulmonary hypertension coronary ischemia and the need for revascularization prior to TAVIRequirements of TAVI TAVI should be performed in regional centers of excellence with a dedicated heart valve program and h

14、igh procedural volumes The procedure may be undertaken in a cardiac catheterization laboratory with modifications or in a hybrid operating room equipped with high-quality fluoroscopic imagingRequirements of TAVI The facilities need to be large enough to accommodate sophisticated X-ray imaging integr

15、ated with echocardiography,cardiopulmonary bypass and intra-aortic balloon pump machines,and anesthesia equipment,with surgical sterility standards mandatoryTechniques of TAVI TAVI is most often performed utilizing the transfemoral retrograde approach Alternative access approaches usually reserved f

16、or patients with concomitant severe peripheral arterial diseaseTransfemoral Approach The common femoral artery,at the level of the femoral head,is the primary access site for the transfemoral approach owing to its relatively large size and compressibility The side with the largest and least diseased

17、,tortuous,or calcified iliofemoral arteryas assessed by a screening angiogramand/or multidetector computed tomographic(CT)angiographyis selected for placement of the sheathTransfemoral Approach The potential site of access is assessed fi rst with fluoroscopy and/or ultrasound,and arterial access is

18、gained by percutaneous puncture Alternatively,a surgical cutdown is utilized to access the femoral artery A smaller percutaneous sheath is inserted into the femoral artery on the contralateral side for placement of a pigtail catheter in the ascending aorta for root angiographyBalloon-expandable valv

19、es are deployed under rapid ventricular pacing at a rate of 160220 bpm to minimize cardiac output and therefore minimize unintentional motion of the valve during balloon dilatationAortic angiographyBoth received CE Mark approval for European commercial sale in 2007Conduction DisturbanceTransapical A

20、pproachTransapical Approachsevere respiratory diseaseRequirements of TAVIThe procedure may be undertaken in a cardiac catheterization laboratory with modifications or in a hybrid operating room equipped with high-quality fluoroscopic imagingTransaortic ApproachTransfemoral Approach The TAVI procedur

21、e may be performed under local or general anesthesia Following balloon valvuloplasty,the valve prosthesis is passed across the aortic valve and positioned under fluoroscopic and transesophageal echocardiographic(TEE)guidanceTransfemoral Approach Balloon-expandable valves are deployed under rapid ven

22、tricular pacing at a rate of 160220 bpm to minimize cardiac output and therefore minimize unintentional motion of the valve during balloon dilatationTransapical Approach The transapical approach was first described in 2006 with balloon-expandable valves A sheath is placed surgically in the left vent

23、ricular apex,accessed through a small left anterolateral minithoracotomyTransapical Approach Following balloon valvuloplasty,the valve prosthesis and balloon catheter are passed over a wire into the left ventricle and positioned within the aortic annulus under fluoroscopic and transesophageal echoca

24、rdiographic guidanceTransapical Approach This approach may be considered if the iliofemoral arterial system is of sufficiently small diameter,calcified,or tortuous and not technically suitable for delivery of the device Also taken into consideration is the angulation of the aorta and archTransapical

25、 Approach In particular,a transverse or extremely unfolded ascending aorta may increase the diffi culty of delivery and positioning of the balloon-expandable devices It has been suggested that with advances in device technology and a reduction in delivery system profiles for the transarterial approa

26、ch,alternative access approaches will be limited to less than 30%of TAVR procedures Transapical Approach Contraindications to the transapical approach previous left ventricular surgery using a patch calcified pericardium severe respiratory diseaseTransapical ApproachOthers Axillary/Subclavian Approa

27、ch Transaortic ApproachComplications of TAVI Procedural Complications Vascular Complications Stroke and Neurological Events Coronary Occlusion Valve Malposition and Embolization Renal Impairment Conduction DisturbanceComplications of TAVI Prosthesis-Related Complications ProsthesisPatient Mismatch Paravalvular and Valvular Regurgitation Prosthetic Valve Thrombosis and Endocarditis Question